Healthcare Provider Details

I. General information

NPI: 1912926056
Provider Name (Legal Business Name): COUNTY OF MOULTRIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W HARRISON ST
SULLIVAN IL
61951-1908
US

IV. Provider business mailing address

115 W HARRISON ST
SULLIVAN IL
61951-1908
US

V. Phone/Fax

Practice location:
  • Phone: 217-728-8714
  • Fax: 217-728-7402
Mailing address:
  • Phone: 217-728-8714
  • Fax: 217-728-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number001
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number1659965
License Number StateIL

VIII. Authorized Official

Name: MRS. KELLY J FAULKNER
Title or Position: TREASURER S.F.P.D.
Credential:
Phone: 217-728-8714